# Spradlin v. Social Security Administration Commissioner

> District Court, W.D. Arkansas · January 25, 2022

URL: https://www.frixlaw.com/law-library/cases/10632387

## Case

- **Court:** District Court, W.D. Arkansas
- **Decided:** January 25, 2022
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10632387

## How later opinions describe it (automated extraction)

- holding an ALJ should recontact a treating or consulting physician if a critical issue is undeveloped

## Opinion text

IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FAYETTEVILLE DIVISION

JAMIE SPRADLIN PLAINTIFF
V. Civil No. 5:20-cv-05192-PKH-MEF
KILOLO KIJAKAZI’, Acting Commissioner,
Social Security Administration DEFENDANT

MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION
Plaintiff, Jamie Spradlin, brings this action under 42 U.S.C. § 405(g), seeking judicial
review of a decision of the Commissioner of Social Security Administration (the “CCommissioner”)
denying her claim for supplemental security income (“SST”) under Title XVI of the Social Security
Act (hereinafter “the Act”), 42 U.S.C. § 1382. In this judicial review, the Court must determine
whether there is substantial evidence in the administrative record to support the Commissioner’s
decision. 42 U.S.C. § 405(g).
1. Procedural Background
Plaintiff filed her application for SSI on November 6, 2017,” alleging disability due to
menstrual cramps, bipolar disorder, anxiety, and depression. (ECF No. 12-7, pp. 6, 12-13, 38-39).
An administrative hearing was held on September 19, 2019. (ECF No. 12-3, pp. 21-49). Plaintiff
was present and represented by counsel.

1 Kilolo Kijakazi became Acting Commissioner of the Social Security Administration on July 9, 2021. Pursuant
to Rule 25(d) of the Federal Rules of Civil Procedure, Kilolo Kijakazi should be substituted as the defendant in this
suit. No further action needs to be taken to continue this suit by reason of the last sentence of section 205(g) of the
Social Security Act, 42 U.S.C. § 405(g).
? Plaintiff filed three prior SSI applications. Her 2011 application was denied at the hearing level in August 2012,
while her 2013 and 2014 applications were denied at the initial level in June and December 2014, respectively. (ECF
No. 12-4, pp. 5-12).

Born in 1977, Plaintiff possessed an eleventh-grade education. (ECF No. 12-2, p. 17). She
has no past relevant work (“PRW”) or transferable skills. /d. at 18.
On December 11, 2019, the Administrative Law Judge (“ALJ”) identified Plaintiff's
schizoaffective disorder-bipolar type and panic disorder as severe impairments. (ECF No. 12-2,
p. 14). He concluded she did not have an impairment or combination of impairments that met or
medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix
1, The ALJ then found her capable of performing a full range of work at all exertional levels with
the following mental restrictions: the interpersonal contact is incidental to the work performed; the
required tasks are no more complex than those learned and performed by rote with few variables
and little judgement; and the supervision needed is simple, direct, and concrete. /d. at 15. With
the assistance of a vocational expert (“VE”), he then found there were jobs that exist in significant
numbers in the national economy that Plaintiff can perform, specifically a dishwasher, DOT
318.687-010, and a hand packager, DOT 920.587-018. fd. at 11.
The Appeals Council denied review on August 26, 2020. (ECF No. 12-2, pp. 2-6). Plaintiff
subsequently filed this action. (ECF No. 1). Both parties have filed appeal briefs (ECF Nos. 15,
16), and the matter is ready for Report and Recommendation.
II. Applicable Law
This Court’s role is to determine whether substantial evidence supports the
Commissioner’s findings. Vossen v. Astrue, 612 F.3d 1011, 1015 (8th Cir. 2010). Substantial
evidence is less than a preponderance, but it is enough that a reasonable mind would find it
adequate to support the Commissioner’s decision. Biestek v. Berryhill, 139 S.Ct. 1148, 1154
(2019), We must affirm the ALJ’s decision if the record contains substantial evidence to support
it. Blackburn v. Colvin, 761 F.3d 853, 858 (8th Cir. 2014). If there is substantial evidence in the

record that supports the Commissioner’s decision, the Court may not reverse it simply because
substantial evidence exists in the record that would have supported a contrary outcome, or because
the Court would have decided the case differently. Miller v. Colvin, 784 F.3d 472, 477 (8th Cir.
2015). In other words, if after reviewing the record it is possible to draw two inconsistent positions
from the evidence and one of those positions represents the findings of the ALJ, we must affirm
the ALJ’s decision. /d.
A claimant for Social Security disability benefits has the burden of proving her disability
by establishing a physical or mental disability that has lasted at least one year and that prevents
her from engaging in any substantial gainful activity. Pearsall v. Massanari, 274 F.3d 1211, 1217
(8th Cir. 2001); see also 42 U.S.C. § 1382c(a)(3)(A). The Act defines “physical or mental
impairment” as “an impairment that results from anatomical, physiological, or psychological
abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.” 42 U.S.C. § 1382c(a)(3)(D). A Plaintiff must show that her disability, not simply
her impairment, has lasted for at least twelve consecutive months.
The Commissioner’s regulations require her to apply a five-step sequential evaluation
process to each claim for disability benefits: (1) whether the claimant has engaged in substantial
gainful activity since filing her claim; (2) whether the claimant has a severe physical and/or mental
impairment or combination of impairments; (3) whether the impairment(s) meet or equal an
impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past
relevant work; and, (5) whether the claimant is able to perform other work in the national economy
given her age, education, and experience. 20 C.F.R. § 416.920(a)(4). The fact finder only
considers Plaintiff's age, education, and work experience in the light of her residual functional
capacity if the final stage of the analysis is reached. 20 C.F.R. § 416.920(a)(4)(v).

III. Discussion
Plaintiff raises four issues on appeal: (1) whether the ALJ fully developed the record; (2)
whether the ALJ erred at Step Two of the sequential analysis; (3) whether the ALJ properly
evaluated her subjective complaints; and (4) whether the ALJ’s RFC determination is supported
by substantial evidence.
Before addressing the evidence, it is important to note that the relevant period in this case
is limited. SSI benefits may not be granted prior to a claimant’s application filing date, because
benefits through an SSI application are allowed only after all regulatory criteria are established.
See 20 C.F.R. § 416.335; Jernigan v. Sullivan, 948 F.2d 1070, 1072 n. 3 (8th Cir. 1991). Further,
more than two years have elapsed from the date of Plaintiff's most recent prior application,
December 2014, and the filing of her current application on November 6, 2017, rendering the
earlier decision ineligible for reopening. See 20 C.F.R. § 416.1488(b) (2019) (initial determination
may be reopened within two years if there is a finding of good cause). Therefore, Plaintiff must
prove that her disability commenced on or after November 6, 2017, her application date, and
continued through December 11, 2019, the date of the ALJ’s decision.
The ALJ does owe a duty to a claimant to develop the record fully and fairly to ensure that
his decision is an informed decision based on sufficient facts. See Stormo v. Barnhart, 377 F.3d
801, 806 (8th Cir. 2004); see also Whitman v. Colvin, 762 F.3d 701, 707 (8th Cir. 2014) (citing
Clark v. Shalala, 28 F.3d 828, 830-31 (8th Cir. 1994)). In so doing, the ALJ should recontact a
treating or consulting physician if a critical issue is undeveloped and order medical examinations
and tests when the medical records presented to him are insufficient to determine whether the
claimant is disabled. Johnson vy. Astrue, 627 F.3d 316, 320 (8th Cir. 2010) (quotation, alteration,
and citation omitted).

Because the Plaintiff had filed several prior SSI applications, the transcript presently before
the Court contains numerous records documenting her mental health treatment prior to, as well as
during the relevant period. These early records are only relevant to the extent that they shed light
on the Plaintiff's mental state during the relevant period. See Cox v. Barnhart, 471 F.3d 902, 907
(8th Cir. 2006) (Records and medical opinions from outside the relevant period can only be used
in “helping to elucidate a medical condition during the time for which benefits might be
rewarded.”). Therefore, while the ALJ could not base his decision solely on these records, he
could consider them in establishing the severity of Plaintiff's mental impairments at or near her
application date.
Plaintiff's history of treatment for depression dated back to at least 2010, for which
Advanced Practical Nurse Sara Butler prescribed Prozac. (ECF No. 12-8, p. 7). At that time, the
Plaintiff was pregnant with her fourth child. Although Prozac was initially beneficial, she was
switched to Zoloft in early 2011. /d. at 22. Following the birth of her child in April 2011, Plaintiff
was diagnosed with postpartum depression. Jd. at 28.
In July 2011, she was treated in the Emergency Room after experiencing a panic attack.
(ECF No. 12-8, p. 52). She explained that her post-partum mood swings and depression were
worse than ever before. Noting a depressed mood with a headache, the doctor diagnosed a panic
attack and depression.
The following month, Dr, Terry Efird conducted a mental evaluation. (ECF No. 12-8, pp.
63-67). Her mood was generally dysphoric, her affect somewhat restricted, and her thoughts
primarily logical and goal directed. However, she endorsed dreaming about demons and “sensing
evil spirits.” Dr. Efird diagnosed panic disorder with agoraphobia and depressive disorder. He

found no remarkable problems with her attention, concentration, persistence, or pace, and
concluded she had the mental capacity to persist if she desired to do so.
In October 2011, Plaintiff began formal mental health treatment with Gary Greenwood, a
Licensed Professional Counselor, and Alice Slavens, an Advanced Practical Nurse, at Western
Arkansas Counseling and Guidance Center (““WACGC”). (ECF No. 12-8, pp. 88-98). They
diagnosed her with paranoid schizophrenia and bipolar I disorder with psychotic features. For this,
they prescribed psychotherapy, an increased dosage of Zoloft, and a trial of Latuda.
On May 21, 2012, Mr. Greenwood prepared an assessment of the Plaintiff. (ECF No. 12-
8, pp. 111-112). He indicated that she sometimes experienced psychotic symptoms that caused
problems in her personal relationships, social interactions, and work settings. Further, her manic
moods resulted in distracted, tangential thoughts, behaviors, and actions. Plaintiff also tended to
isolate, withdraw, and fail to fulfill her obligations. Regarding her attention and concentration,
Mr. Greenwood noted that, at times, she appeared to show some rational thinking and cognitive
control, however, these occasions were both minimal and fleeting. During his interactions with
her, she had difficulty answering questions without getting distracted. And despite being on
several medications, her overall improvement was only minimal. She remained very anxious in
social situations and experienced paranoia. Unfortunately, the Plaintiff was never consistent in
her responses to her environment, her friends, her past work situations, or in her therapy
attendance.
On October 9, 2014, Plaintiff was evaluated by Dr. Gene Chambers. (ECF No. 12-8, pp.
115-120). After reviewing her medical records, Dr. Chambers noted they were consistent with a
history of psychosis, depression, and anxiety. While she reported a history of depression and
visual hallucinations dating back to her childhood, she explained that her symptoms intensified

during her 20s. At that time, she also began to experience mood swings. When her mood was
high, she was very energetic, cleaned a lot, did not sleep, and spent money irresponsibly. When
her mood was low, she was despondent, paranoid, and verbally abusive. According to Plaintiffs
estimates, she experienced one manic episode per month and both her manic and depressed moods
typically lasted two to three days. Plaintiff also reported experiencing panic attacks, averaging
once per week. Noting her to be both depressed and anxious, Dr. Chambers diagnosed
schizoaffective disorder - bipolar type, panic disorder, and agoraphobia. He assessed moderate
limitations in her ability to communicate and interact socially; communicate in an intelligent and
effective manner; and cope with the typical mental/cognitive demands of basic work-like tasks.
Further, he noted moderately severe limitations in her ability to attend and sustain concentration,
to sustain and complete work-like tasks, and to complete work-like tasks within an acceptable time
frame.
Beginning in December 2016, psychiatrist, Dr. Donald Chambers, took over Plaintiff's
care. (ECF No. 12-9, p. 3). Although she did not feel that her medications were working, Dr.
Chambers increased her Klonopin and Abilify, prescribed Neurontin, and discontinued the
Wellbutrin. In January and March 2017, Plaintiff reported doing very well with no depression.
Id. at 4-6. She remained stable at her June follow-up and Dr. Chambers indicated that although he
was still considering the addition of a new medication, he would make no changes due to her
progress. Jd. at 7. It appears, however, that he later prescribed Trintellix, as she reported some
gastrointestinal side effects during her October follow-up. Jd. at9. Noting her to be less depressed,
Dr. Chambers agreed to prescribe Cymbalta, but he had to switch her to Paxil because she could
not obtain the Cymbalta. Jd. at 10. On October 27, 2017, he noted it to be working well. Id.

On February 13, 2018, Dr. Patricia Walz diagnosed Plaintiff with schizoaffective disorder-
bipolar type, and panic disorder. (ECF No. 12-9, pp. 57-60). Plaintiff again endorsed seeing and
hearing demons and reported she dropped out of school after the 11th grade because she “just
couldn’t do it anymore.” Her mood was anxious, her affect was flat, and when questioned, she
tended to give extraneous details and repeat herself, requiring Dr. Walz to interrupt her to go on to
the next question. Moreover, her speech was pressured, her thoughts circumstantial, and her
estimated IQ low average. Dr. Walz opined that Plaintiff's social skills were impaired by her
anxiety, her psychotic symptoms interfered with her ability to learn and retain skills, her attention
and concentration were impaired, she was distracted by internal stimuli, and her speed of
information processing was slow.
Two days later, Dr. Abesie Kelly, reviewed the record, including Dr. Walz’s assessment
and records from her treating psychiatrist, Dr. Donald Chambers, and found Plaintiffto have severe
bipolar and generalized anxiety disorder that resulted in moderate limitations in her ability to
understand, remember, and apply information, and to concentrate, persist, and keep on pace. (ECF
No. 12-4, pp. 25-28). In August, Dr. Steve Brown affirmed Dr. Kelly’s assessment, noting Plaintiff
could perform work where the interpersonal contact was incidental to the work performed, e.g.,
assembly work; the complexity of the tasks was learned and performed by rote with few variables
and little judgment; and the supervision required was simple, direct, and concrete.
Records indicate that Plaintiff began receiving her medication refills from her primary care
physician (“PCP”), Dr. Michael Guyer, in late 2018, when Dr. Chambers retired. (ECF No. 12-
12, p. 48). In February 2019, Dr. Guyer noted she was doing well on her current medications with
no new problems or complaints. /d. at 95.

Two months later, Plaintiff established care with psychiatrist, Dr. Keith Berner. (ECF No.
12-2, pp. 47-50). She reported weekly mood swings, paranoia, depression, and continued
hallucinations, indicating she saw herself as a psychic. Plaintiff requested a higher dosage of
Clonazepam or to switch to another Benzodiazepine. Dr. Berner was not comfortable with this
and voiced some concern that Dr. Chambers’ records did not document a clear diagnosis of
attention deficit hyperactivity disorder (“ADHD”); however, because she described long-standing
academic struggles and anxiety, he found this could be evidence of ADHD and continued the
Adderall. Noting her history of instability and hallucinations that now appeared to be stable, Dr.
Berner added Prazosin, recommended increased social interaction, and advised talk therapy.
In May 2019, her depression was worse, but the medications were helpful in controlling
her psychosis. (ECF No. 12-2, pp. 44-46). Dr. Berner prescribed a taper off the Paroxetine and
noted he would make only one medication change at a time.
On June 26, 2019, she phoned his office five times, requesting an early refill of her
Adderall. (ECF No. 12-2, p. 42). Dr. Berner noted her prescription was not due for renewal until
June 30, but he would allow her to refill it four days early. He advised her, however, that repeated
phone calls were counterproductive and could result in her dismissal from the clinic.
During a follow-up in early July, Plaintiff reported recently separating from her husband.
(ECF No. 12-2, pp. 39-41). Despite her prior reports that their relationship was good, and he was
very supportive, she now divulged he was an alcoholic with a possible porn addiction. She
indicated he had “taken everything that was worth anything,” including the car, and he now wanted
their mobile home. As a result, Plaintiff was struggling more with her mood and feeling alone and
abandoned, Dr. Berner discontinued the Prazosin, as it was not helpful, but renewed her Adderall,
Abilify, Clonazepam, and Duloxetine prescriptions and added Mirtazapine.

On July 22, 2019, she again phoned the doctor’s office multiple times asking for an early
refill of her Adderall. (ECF No. 12-2, p. 39). Dr. Berner explained that he was not comfortable
with consistent early refills of this medication, and again warned her about repeated phone calls.
On August 12, 2019, allegedly without notice, Plaintiff's insurance status changed to
Medicaid only. (ECF No. 12-2, p. 35). Because Dr. Berner was not a Medicaid provider, this
required her to again obtain her prescriptions from Dr. Guyer. To notify him of this change in
status, Plaintiff telephoned Dr. Berner’s office 13 times in less than 20 minutes, from 2 different
numbers, until he answered the phone. Hoping the issue would be solved quickly, she advised
him that she would keep her September appointment with him. Dr. Berner phoned Dr. Guyer’s
nurse, who assured him that Dr. Guyer would fill her prescriptions in the interim. /d. at 35.
One week later, Plaintiff advised Dr. Berner by voicemail that she would be receiving all
treatment from Dr. Guyer and would no longer need his services. (ECF No. 12-2, p. 34). Despite
this, Dr. Berner received a fax from Walgreens on August 21, requesting assistance in handling
Plaintiffs repeated requests for early Adderall refills. /d. at 33. They also advised him that she
had only been picking up her Adderall and Clonazepam prescriptions, not the other medications
he had prescribed. Given that she had cancelled his services, he advised Walgreens that she was
no longer his patient.
On August 22, 2019, Plaintiff left five additional angry voicemail messages for Dr. Berner.
(ECF No. 12-2, p. 33). She cursed at him for allegedly “red flagg[ing]” her. Two days later, Dr.
Berner received another series of angry phone calls from Plaintiff, during which she cursed at him
and accused him of ruining her life. /d. at 32. She also stated she discontinued all her medications,
“cold turkey,” and would be going back to “street drugs.” As a result, Dr. Berner again reached
out to Dr. Guyer’s nurse to apprise them of the situation.

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The ALJ dismissed Dr. Walz’s opinion, finding her notations of Plaintiffs impaired
attention and concentration and psychotic symptoms that would interfere with her ability to learn
and retain skills to be vague. (ECF No. 12-2, p. 17). He also found no evidence to support a
finding that the Plaintiff would have difficulty learning or retaining skills. The ALJ did not,
however, recontact Dr. Walz to obtain clarification of her vague assessment. See Johnson, 627
F.3d at 320 (holding an ALJ should recontact a treating or consulting physician if a critical issue
is undeveloped). Moreover, he failed to discuss Plaintiffs eleventh-grade education, her history
of academic struggles, or Dr. Gene Chambers’ 2014 assessment of moderately severe limitations
in her ability to attend and sustain concentration, to sustain and complete work-like tasks, and to
complete tasks within an acceptable time frame. He also failed to mention Dr. Donald Chambers’
opinion that the Plaintiff could not work due to her mental impairments. (ECF No. 12-9, p. 76).
Instead, the ALJ relied heavily on treatment records indicating that Plaintiff's
schizoaffective disorder, bipolar disorder, and anxiety responded well to the medications
prescribed. But he failed to discuss Dr. Berner’s 2019 records documenting her treatment
noncompliance, repeated requests for early medication refills, and harassing behavior. These
behaviors certainly suggest that Plaintiff’s condition was not well controlled and would interfere
with her ability to work with others.
We note that it is not uncommon for patients suffering from bipolar disorder and/or
schizoaffective disorder to discontinue their medications at will. See DIAGNOSTIC AND
STATISTICAL MANUAL OF MENTAL DISORDERS 5 (DSM-5) 129 (Sth ed. 2013);
Charolette E. Grayson, Bipolar Disorder: Taking Your Bipolar Medication, at www.webmd.com.
According to the DSM, patients suffering from schizoaffective disorder and bipolar disorder suffer
from anosognosia, or poor insight. DSM-5 129 (4th ed. 2000). “Evidence suggests that poor

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insight is a manifestation of the illness, rather than a coping strategy.... This symptom predisposes
the individual to noncompliance with treatment and has been found to be predictive of higher
relapse rates, increased number of involuntary hospital admissions, poorer psychosocial
functioning, and a poorer course of illness.” Jd. These disorders are also frequently associated
with substance abuse. Luke Archibald, et al., ALCOHOL USE DISORDER AND SCHIZOPHRENIA OR
SCHIZOAFFECTIVE DISORDER NATIONAL INSTITUTE □□ ALCOHOL ABUSE AND ALCOHOLISM (2019),
found at https://arcr.niaaa.nih.gov/alcohol-use-disorder-and-co-occurring-mental-health-
conditions/alcohol-use-disorder-and-schizophrenia-schizoaffective-disorder (last visited January
24, 2022); Frederick K. Goodwin & Kay Redfield Jamison, MANIC-DEPRESSIVE ILLNESS 219-25
(2d ed. 1990); Li-Tzy Wu et al., “Influence of Comorbid Alcohol and Psychiatric Disorders on
Utilization of Mental Health Services in the National Comorbidity Survey,” 156 Am. J. Psychiatry
1235 (1999); Edward J. Khantzian, “The Self-Medication Hypothesis of Addictive Disorders:
Focus on Heroin and Cocaine Dependence,” 142 Am. J. Psychiatry 1259, 1263 (1985). Substance
abuse serves as a means by which the sufferer tries to alleviate their symptoms. Jd. The ALJ,
however, failed to consider either of these factors, and for this reason, we find that remand is
necessary.
On remand, the ALJ should be directed to order a second consultative mental evaluation
with Dr. Patricia Walz, affording her the opportunity to reevaluate the Plaintiff, review Plaintiff's
most recent treatment records, and clarify her opinion that Plaintiff's attention and concentration
were impaired and that her psychosis would interfere with her ability to learn and retain skills.
The ALJ should also ask Dr. Walz to weigh in on whether the Plaintiff's noncompliance, harassing
behavior toward Dr. Berner, and potential Adderall abuse are related to her diagnoses of
schizoaffective disorder and bipolar disorder. Should Dr. Walz be unavailable or otherwise unable

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to conduct a second consultative exam, the ALJ should be ordered to obtain a consultative mental
evaluation from another mental health professional to address these issues.
IV. Conclusion
Based on the foregoing, I recommend reversing and remanding this case to the
Commissioner for further consideration pursuant to sentence four of 42 U.S.C. § 405(g).
The parties have fourteen (14) days from receipt of our report and recommendation
in which to file written objections pursuant to 28 U.S.C. § 636(b)(1). The failure to file timely
objections may result in waiver of the right to appeal questions of fact. We remind the parties
that objections must be both timely and specific to trigger de novo review by the district
court.
DATED this 25th day of January 2022.

isi Mark €. Ford
HON. MARK E. FORD
CHIEF UNITED STATES MAGISTRATE JUDGE

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